Current size and density of HRH
Using NSSO and NHWA data, we estimated current size of HRH at the all-India level (Table 2). Mainly, three parameters are presented: 1) total production of health professionals, 2) actual stock of health professionals and 3) active health workforce. NHWA data reported 1.16 million doctors, 2.34 million nurses/midwives as total production in the country as of 2018. The data also records approximately 0.79 million AYUSH practitioners.
Table 2
Size and composition of HRH in India
| Total production, 2018 | Actual stock, 2018* | Active health workforce 2019^ | Active health |
Parameters | Number (in million) | Density / 10000 population | Number (in million) | Density / 10000 population | Number (in million) | Density / 10000 population | workforce as % of Actual stock |
Allopathic doctor | 1.16 | 8.8 | 1.05 | 7.9 | 0.66 | 5 | 63 |
Nurses /midwives | 2.34 | 17.7 | 2.18 | 16.5 | 0.79 | 6 | 36 |
Allopathic doctors + Nurses /midwives | 3.5 | 26.5 | 3.23 | 24.4 | 1.45 | 11 | 45 |
AYUSH practitioners | 0.79 | 6 | 0.76 | 5.8 | 0.25 | 1.9 | 33 |
Allopathic doctors + Nurses /midwives + AYUSH | 4.29 | 32.5 | 3.99 | 30.2 | 1.7 | 12.9 | 42.6 |
Sources: NHWA 2018 and PLFS 2018-19. |
Notes: *Adjusted for attrition (Out-migration): Allopathic Doctors: (- 6 %); Nurses: (- 3.3 %), death rate (for both nurses and doctors:(-2.5% to -2.1%), retirement rate(doctors):(-1.07%), retirement rate(nurses):(-1.02%); ^Estimated from PLFS:2018-2019 after accounting for adequate qualifications and population projection as of January 2019 (Census of India 2019). |
Total stock of health professionals as of 2018 are estimated to be 1.05 million doctors and 2.18 million nurses/midwives. However, the size of the estimated active health workforce, is considerably lower, 0.66 million doctors and 0.79 million nurses/midwives. At the aggregate level, adding numbers of doctors and nurses/midwives together the size of active health workforce is around 45% of the total actual stock of health professionals. Accordingly, the density, of health professionals available in stock is 24.4 per 10,000 population when considering only allopathic doctors and nurses/midwives. However, including AYUSH professionals the density of health worker stock increases to 30.2 per 10,000 population. Density of active health workforce is estimated to be around 11 and 12.9 by excluding and including AYUSH respectively.
As far as skill-mix of HRH is concerned, doctor: nurse/midwives ratio is estimated to be 1:2 in the production and stock data, while active health workforce data reflects 1:1.2 ratio. This essentially reflects that proportion of qualified nurses/midwives not active in human health service is much larger as compared with that of doctors (12, 18).
Supply side estimates of HRH
Table 3 presents the projections of total cumulative production, stock of health professionals and active health workforce, separately for doctors, nurses/midwives and AYUSH practitioners by the year 2030. As of 2030, total cumulative production will be 2.06 million doctors while only a little over half of this supply (1.1 million) will be working in health services. While the actual available stock in nurses/midwives will be 2.74 million by 2030, only about half (1.4 million) of this stock will be active health workforce.
Table 3
Projected estimates of HRH, by 2030
Parameters | Doctors | Nurses /midwives | Doctors +Nurses /midwives | AYUSH | Doctors +Nurses /midwives +AYUSH |
Total production of health professionals (in million)* | 2.06 (14.1) | 3.94 (26.9) | 6 (41) | 1.29 (8.8) | 7.29 (49.8) |
Total stock of health professionals (in million)** | 1.51 (10.3) | 2.74 (18.7) | 4.25 (29) | 0.93 (6.4) | 5.18 (35.4) |
Active health workforce (in million)^ | 1.1 (7.5) | 1.41 (9.6) | 2.51 (17.1) | 0.51 (3.5) | 3.02 (20.6) |
Sources: NHWA 2018; PLFS 2018-19 and Census of India 2011. |
Notes: *includes estimated pass-outs from all institutions established and announced to be established by 2025; **adjusted for attrition (mortality, retirement and migration);^Estimated from PLFS:2018-19, moderate labour market attrition of 20%-doctors and 30%-Nurses and attrition (mortality, retirement and migration). Figures in parentheses are density per 10000 persons. Doctors-Net migration rate:(+5%), death rate:(-2.5 to -2.1%), retirement rate:(-1.07%) and Nurses(/midwives)-Annual Migration:(-4.6%), death rate:(-2.5 to -2.1%), retirement rate:(-1.02%). |
Moreover, the total stock of HRH including doctors and nurses/midwives by the year 2030 will be about 4.25 million and 5.18 million without and with AYUSH professionals respectively. However, there will be only 2.51 million doctors and nurses /midwives in the active health workforce. Including AYUSH in the workforce, the number of active health workers increases to 3.02 million by 2030. The density of health professionals is about 29 skilled health professionals per 10,000 persons when considering the stock, which comes down to 17.1 skilled doctors and nurses/midwives in the active health workforce. If we include AYUSH professionals, the density is around 20.6 skilled doctors and nurses/midwives in active health workforce.
Health worker shortages at different thresholds
The required number of doctors and nurses (/midwives) to meet the overall HRH: population ratio thresholds of 34.5 and 44.5 per 10,000 population (2, 4, 40–44) were estimated assuming a doctor: nurses/midwives ratio of 1:2 (Appendix Table A-1). The stock shortage for doctors is 0.16 million by the year 2030 at the 34.5 density threshold (Figure 1). The shortages at the same threshold are much higher (0.57 million) for doctors in active health workforce. At the density of 44.5, both the stock and active health workforce are reporting doctor shortage of 0.64 million and 1.05 million respectively. The nurse’s shortage in stock reaches up to 0.65 million by the year 2030 to meet the density threshold of 34.5. The shortages at the same threshold are more than three-folds (1.98 million) if we consider the number of nurses /midwives actively working. At the density threshold of 44.5 skilled health worker per 10,000 population, the shortages of nurse/midwives in the stock and active health workforce are estimated to be approximately 1.63 million and 2.96 million respectively by 2030.
Strategies and required levels of investment
The strategies to increase the production of doctors and nurses/midwives by expanding the seat capacity of the existing institutions or opening new institutions or both are presented in Table 4. Total number of existing and upcoming institutions by 2025 are 675 medical colleges and 7,110 nursing institutes with respective seat capacity of 95,325 and 289,000 (Appendix Table A-II). Given the total number of institutions and average annual pass-outs of 136 doctors and 19 Nurses/midwives per institution, there is significant scope to increase the number of seats and institutions. However, for the increased production of nurses/midwives, improved utilization of the existing capacities would be crucial. Currently only 19 nurses on an average per institution pass-out annually with the existing capacity of 41 seats per nursing institution.
Table 4
New investment required for meeting the doctors and nurses/midwives shortages at different health worker: population ratio thresholds, by 2030
Parameters | Health worker density threshold^ | Required new production (‘000’) per annum during 2021-25* | Required number of seat expansion per college (Total seats ‘000’) | Required number of new colleges (Total seats ‘000’) | Estimated total cost of investment (In INR billion)^^ |
Lower bound of investment – Actual stock shortages |
Doctors | 34.5 | 39 | 39(26) | 87(13) | 523 |
| 44.5 | 160 | 39(26) | 892(134) | 2,941 |
Nurses /midwives | 34.5 | 161 | 21(149) + 2(14)** | 0 | 0 |
| 44.5 | 406 | 21(149) + 20 (142)*** | 1,918 (115) | 707 |
Upper bound of investment – Active health workforce shortages |
Doctors | 34.5 | 142 | 39(26) | 772 (116) | 2,580 |
| 44.5 | 263 | 39(26) | 1,578(237) | 4,998 |
Nurses /midwives | 34.5 | 494 | 21(149) + 20(142)*** | 3,385(203) | 1,096 |
| 44.5 | 740 | 21(149) + 20(142)*** | 7,475(448) | 2,180 |
Middle bound of investment- by considering 50% of the out of workforce qualified health personnel into active health workforce ^^^ |
Doctors | 34.5 | 95 | 39(26) | 458(69) | 1,636 |
| 44.5 | 216 | 39(26) | 1,263(189) | 4,053 |
Nurses /midwives | 34.5 | 357 | 21(149)*** + 20(142) | 1,100(66) | 491 |
| 44.5 | 603 | 21(149)*** + 20(142) | 5,190(311) | 1,574 |
Note: ^ Skilled health worker density per 10,000 population*Required production per annum for a duration of 4 years (Total required production/4); ^^Doctors: The investment estimates includes cost of seats (INR 10 million per seat) expansion in existing (/proposed) colleges and cost of opening new institutions (INR 3,000 million per institution) and for nurses(/midwives): The investment estimates includes cost of seats (INR 1.4 million per seat) expansion in existing (/proposed) colleges and cost of opening new institutions (INR 265 million per institution);**includes increasing pass-out rate in existing institution by 21 seats per institution (no cost involved) and seat expansion by 2 per institution (cost not considered for increasing 2 seat per institution);***includes increasing pass-out rate in existing institution by 21 seats per institution (no cost involved) and seat expansion by 20 per institution (INR 1.4 million per seat) ^^^Doctors: Annual shortages estimated after including 50% of medically qualified health professionals who are not part of health workforce (0.19 million doctors) to the total shortages by 2030 and in nurses(/midwives), annual shortages estimated after including 50% of medically qualified health professionals who are not part of health workforce (0.55 million nurses(/midwives) to the total shortages by 2030. |
Given the levels of infrastructure in the existing institution, an increase of 35-40 seats per institutions in medical colleges and 20 seats per institution in nursing institute is possible. The remaining shortages can be bridged by opening new institutions. Increasing 35-40 seats in medical colleges and 20 seats in nursing institutions on average will lead to an average seat capacity of 170-175 seats per medical college and 61 seats per nursing institutes (Table 4). In such scenario an additional 87 medical college with similar seat capacity will be required to meet the stock shortage of doctors at the 34.5 density threshold. There will be no need of opening new nursing institutes as improved pass-out rate will be almost equal to the stock shortages in nurses at the 34.5 density threshold. However, to bridge the stock shortages at the 44.5 threshold there will be requirement of opening 892 new medical colleges and 1,918 new nursing institutions along with seat expansion in the existing institutions.
Further, to bridge the shortages of active health workforce, along with the seat expansion there will be requirement of opening 772 new medical colleges and 3,385 new nursing institutes at the 34.5 threshold and 1,578 medical colleges and 7,475 nursing institutes at the density threshold of 44.5. With lower seat expansion, the shortages can be met only by opening higher number of institutions ranging from 87 and 1,691 medical colleges depending on the gaps to be met in stock or active health workforce on the one hand and 34.5 and 44.5 density thresholds on the other (Appendix Table A-III).
Accordingly, the required levels of investment were estimated by applying unit costs (INR 10 million for one seat expansion and INR 3,000 million for opening one medical college for doctors and INR 1.4 million for one seat expansion and INR 265 million for opening one new nursing institute) over the total number of seat expansion and new institutions required to be increased. The size of the required investment varied depending on the gaps to be met in stock or active health workforce on the one hand and 34.5 and 44.5 density thresholds on the other. Meeting the HRH shortage and required investment in stock and active health workforce are two extreme bounds (call it lower bound and upper bound). To meet the stock gaps, the required investment ranged between INR 523 billion and INR 2,941 billion at the density thresholds of 34.5 and 44.5 respectively. For stock of nurses, the required investment is about INR 707 billion at the density thresholds of 44.5. However, bridging the shortages of active health workforce at the 34.5 density threshold, investment requirements are INR 2,580 billion for doctors and 1,096 for nurses/midwives. At the 44.5 threshold, the investment requirements are INR 4,998 billion for doctors and INR 2,180 billon for nurses/midwives.
We also present a medium bound of investment (Table 4), which has been estimated by considering inclusion of 50% of the qualified health professionals who are out of labour force. If efforts are made to attract at least 50% of the out of labour force health professionals to be part of the active health workforce there will be an investment requirement of INR 1,636 and INR 4,053 billion at the density thresholds of 34.5 and 44.5 respectively for bridging the shortage of doctors by 2030. For bridging the gaps in nurses/midwives the respective investment requirements are estimated to be INR 491 and INR 1,574 billion. Different other scenarios of combinations of seat expansion and opening new institutions are presented in Appendix Table A-IV. However, the estimated costs doesn’t include the likely costs of different efforts, other than opening new institutions and seat expansion.
In yet another alternative scenario, we only considered seat expansion in government medical colleges. In this scenario, we estimated an additional capacity of 26,726 seats in government medical colleges by increasing the seats intake up to 200 per college, exclusively in colleges with current uptake below 200. The required investment under this scenario is estimated to be INR 519 to 2,576 billion at the 34.5 threshold and INR 2,973 to 4,993 billion at the 44.5 threshold (Figure 2). We also estimated the potential shortages in doctors and the related investment requirement by considering AYUSH as part of active health workforce (Figure 2) and the estimated investment requirement for bridging the doctors’ shortage is INR 146 and INR 2,446 billion at threshold 34.5 and 44.5 respectively (Appendix Table A-IV).
Economic benefits of investment in HRH, by 2030
Although investment in HRH has multiple pathways to economic growth (8, 45), in the present study we only estimated potential benefits in terms of employment generation and labour productivity. We used the quantum of investment required for overcoming the HRH shortages in active health workforce as the benchmark for estimating the potential employment generation and labour productivity benefits. At the density threshold of 34.5, the estimated upper bound of investment of INR 3,676 billion has the potential to create employment for 5.4 million health workers. The additional employment of 2.55 million, consisting of doctors and nurses/midwives can generate new 1.51 million employment of support staff and 1.35 million health associate personnel separately, after adjusting for a labour market attrition rate of 20%. The labour productivity (GVA/employment) per worker in the health sector for the year 2019-20 is estimated to be INR 633 thousand. Using this estimated labour productivity in 2030 reflects that the marginal GVA (due to the additional employment generated by 2030) could be INR 3,429 billion during 2026-30 (Table 5).
Table 5
Estimates of benefits of investment in terms of new employment and contribution to national gross value added by 2030
Parameter | Required HRH Investment during 2021-25 | New employment generation (In million) | Total gross value added during 2026-30 |
| (In billion) | health workers | Support staff* | Health associate** | Total | (In billion) |
34.5 skilled health worker per 10000 population | 3,676 | 2.55 | 1.51 | 1.35 | 5.42 | 3,429 |
44.5 skilled health worker per 10000 population | 7,178 | 4.01 | 2.38 | 2.13 | 8.52 | 5,392 |
Note: *Supportive staff include other support workers such as administrators, clerks, accountants, motor drivers, garbage collectors etc.; ** Includes health associates such as nutritionists, dieticians, optometrists etc. |
At the higher density threshold of 44.5 the benefit in the health sector is to the tune of INR 5,392 billion annually with the required investment of INR 7,178 billion. Here it is important to note that the estimated investment is a one-time requirement to be completed during the period of 2021-2025 but the contribution to GVA because of the increased employment will be each year for a long period of time. If the required investment is spread over a period of 4 years (during 2021-25), the same is estimated to be 0.4% and 0.8% of GDP at the 34.5 and 44.5 density thresholds respectively.